The Fire Fighter Fatality Investigation andPrevention Progra.docx

The Fire Fighter Fatality Investigation and
Prevention Program is conducted by the National
Institute for Occupational Safety and Health (NIOSH).
The purpose of the program is to determine factors that
cause or contribute to fire fighter deaths suffered in the
line of duty. Identification of causal and contributing
factors enable researchers and safety specialists to
develop strategies for preventing future similar incidents.
To request additional copies of this report (specify the
case number shown in the shield above), other fatality
investigation reports, or further information, visit the
Program Website at:
http://www.cdc.gov/niosh/firehome.html
or call toll free 1-800-35-NIOSH
Fire Fighter Fatality Investigation
and Prevention Program
Death in the
line of duty...
A summary of a NIOSH fire fighter fatality investigation
November 30, 1998
Sudden Floor Collapse Claims the Lives of Two Fire Fighters
and Four Are
Hospitalized with Serious Burns in a Five-Alarm Fire--New
York
SUMMARY

On June 5, 1998, a call came into fire dispatch
reporting a fire in the boiler room at
residential/commercial complex. Several units
were dispatched, and upon arrival, Engine 332
reported smoke emitting from the building. The
building involved in the fire was one of five
three-story wood frame dwellings (see Figure 1).
The fire building (building #1) and the collapse
building (building #2) were both owned by the
City, with some of the units occupied and some
vacant. The building, which had undergone
renovations over the past several years, was built
around the turn of the century. The fire
department initiated fire fighting operations, and
several fire fighters were conducting an interior
attack on the first floor of one of the dwellings,
when it was reported that a civilian was trapped
on the second floor. The Captain (Victim #1)
and a fire fighter on Ladder 176, the Lieutenant
(Victim #2) and two fire fighters on Engine 332,
and the Lieutenant on Ladder 103 went to the
second floor to search for the trapped civilian.
Without warning, approximately 10 minutes
after the arrival of
the first unit, the rear of the second floor of
building #2 collapsed, trapping five fire fighters in
a burning inferno on the first floor. NIOSH
investigators conclude that, to minimize the
chances of similar occurrences, fire departments
should:
• ensure that Incident Command
conducts a thorough initial size up of
the incident before initiating fire
fighting efforts, and continually

evaluates the risk versus gain during
operations at an incident
• ensure that Incident Command always
maintains close accountability for all
personnel at the fire scene
• ensure that some type of tone or alert
that is recognized by all fire fighters be
transmitted immediately when
conditions become unsafe for fire
fighters
Fatality Assessment and Control Evaluation
Investigative Report #98F-17
and Four Are Hospitalized with
Serious Burns in a Five-Alarm Fire--New York
Page 2
• ensure that Rapid Intervention
Crews/Teams or Firefighter Assist and
Search Teams (FAST Truck) are in
place in the early stages of an incident
• ensure that communication equipment
used on the fireground, e.g., handie-
talkies, will remain operational in the
event that one unit malfunctions.

NIOSH investigators also concluded that, to
prevent similar occurrences, municipalities
should:
• ensure that modifications/renovations
to buildings are in compliance with
applicable building codes, i.e., any
renovation or remodeling does not
decrease the structural integrity of the
supporting members.
INTRODUCTION
On June 5, 1998, several fire fighters were
conducting an interior attack on the first floor of
a wood frame, multiple residential dwelling,
when it was reported that a civilian was trapped
on the second floor. The Captain (Victim #1)
and a fire fighter on Ladder 176, the Lieutenant
(Victim #2) and two fire fighters on Engine 332,
and the Lieutenant on Ladder 103 went to the
second floor to search for the trapped civilian.
The fire fighter on Ladder 176 went to the front
and the other officers and fire fighters went to
the rear of the structure to conduct a search.
Within a few minutes and without warning, the
floor at the rear of the structure collapsed,
trapping all five in a live fire situation on the first
floor. Two fire fighters died and four were
seriously injured (includes the fire fighter on
Ladder 176 that dove over the stairwell railing).
It was reported later that the trapped civilian had
escaped through a back entrance.

On June 22-25, 1998, and September 15-17,
1998, an investigation of this incident was
conducted by the Chief of the Trauma
Investigations Section, Division of Safety
Research. Meetings were conducted with the
Chiefs of the Fire Department Safety Command
(Fire Fighter Fatality Investigation Team), the
Chief of Safety, the Safety and Health
Coordinator, two Battalion Chiefs who
responded to the incident, several fire fighters
that responded to the incident, and a
representative of the International Association of
Fire Fighters (IAFF). A site visit was conducted;
however, the building had already been removed.
Copies of photographs from the incident site
were obtained from the fire department along
with diagrams of the buildings, a video tape of the
incident, and investigative information which
included a detailed time line. Figures, diagrams,
and pictures used in this report were courtesy of
the fire department.
The fire department involved in the incident
serves a population of 7.9 million in a geographic
area of 306 square miles. The fire department has
230 firehouses and is comprised of approximately
15,000 employees, including 11,000 fire fighters
and officers, 3,000 emergency medical service
(EMS personnel), and 1,000 civilians. The fire
department provides all new fire fighters with the
basic 13 weeks of training at their fire academy
that meet or exceed the National Fire Protection
Association (NFPA) Fire Fighter Level I and
Level II. After graduating from the fire academy,

Page 3
the recruit fire fighters go through a 3-year
rotation in which they are assigned to an A (high
activity level), B (moderate activity level), or C
(light activity level) firehouse for 1 year. They
are then rotated to a different activity and
geographic location for the second year, and
rotated again at the beginning of the third year.
Refresher training continues on each shift and
multi-unit drills are conducted continually to
maintain hands-on proficiency. The fire
department has extensive written standard
operating procedures. The Captain (Victim #1)
had 20 years of fire fighting experience, and the
Lieutenant (Victim #2) had 21 years of fire
fighting experience.
Although many fire companies were involved in
this five-alarm incident, only those directly
involved up to the time of the fatal incident are
discussed in this report.
INVESTIGATION

On June 5, 1998, at 2022 hours a call came into
the Dispatch Center reporting a boiler room fire
at a residential/commercial complex. The
structure was one of five attached, three-story,
wood-frame residential/commercial units (see
Figure 1). Engine 332 (Lieutenant [Victim #2]
and four fire fighters), Engine 231 (Lieutenant
and four fire fighters), Engine 290 (Lieutenant
and five fire fighters), Ladder l75 (Captain and
five fire fighters), and Battalion 44 responded.
Engine 332 was the first unit to arrive at 2025
hours, and reported a 1075 (working fire).
Engine 332 and Engine 231 made hydrant
connections close to the building and stretched
hand lines to the front (see Figure 2). Fire
fighters from Ladder 175 (Captain and five fire
fighters) reported in at 2026 hours, and fire
fighters from Engine 231 reported in at 2027
hours and attempted to make an entry on the first
floor of building #1. Battalion 44 arrived at 2027
hours and was conducting a size-up, reporting
heavy fire on the first floor of building #1, when
he received a transmission from the fire fighters
on the first floor of building #1 that the interior
hall had been closed off from the rest of the
building (the interior hall had been closed off
during one of the renovations of the building).
Battalion 44 told the fire fighters on Ladder 175
to breach the wall to gain access into the building.
At that time, Battalion 44 called for an additional
Engine and Ladder to be dispatched.
At 2029 hours, Ladder 176 (Captain [Victim #1]
and six fire fighters) was designated as the
Firefighter Assist and Search Team (FAST)

Truck. Note: A FAST Truck is similar to a
Rapid Intervention Crew/Team.
At 2029 hours Engine 290 arrived, followed by
Ladder 103 at 2030 hours. Engine 332 and
Engine 231 pulled lines to the front of the
structure to prepare for making an interior attack.
A woman who lived at building #2 reported to
Battalion 44 that her mother was still in the
building (see Figure 3). The Lieutenant and two
fire fighters on Ladder 103 responded to the
report that someone was trapped on the second
floor. They were being assisted by the Lieutenant
and three fire fighters on Engine 332.
At 2030 hours, dispatch notified Battalion 44 that
Engine 227 (Captain and five fire fighters) and
Ladder 111 (Lieutenant and five fire fighters)
were the additional Engine and Ladder, and that
Ladder 176 was the designated FAST Truck.
At 2030 hours, Engine 233 (Lieutenant and four
fire fighters) arrived at the rear of the building

and reported to Battalion 44 that heavy fire was
showing in the rear. At 2031 hours, Ladder 175
breached a hole in the first floor hallway of
building #1 to gain entrance into the first floor of
the building. At 2032 hours, Engine 231
directed the line through the breached hole on
the first floor of building #1. At the same time,
the team on Ladder 103 (Lieutenant and five fire
fighters) was at the rear entrance to the second
floor apartment of building #2, and reported fire,
heavy smoke, and heat on the second floor.
Ladder 103 called Battalion 44 and requested a
line. Battalion 44 ordered Engine 332 to pull a
line to the second floor of building #2, and for
the FAST Truck (Ladder 176) to assist in the
search for the missing woman.
At 2032 hours, Battalion 44 called for a second
alarm, which resulted in three more Engines, one
additional Ladder, and the Maxi-water unit.
At 2034 hours Battalion 44 reported to the
dispatcher that they were having trouble locating
the fire, that people were trapped on the upper
floors, and that searches were in progress. The
Lieutenant on Ladder 103, and the Lieutenant
(Victim #2), the Nozzleman, and a fire fighter on
Engine 332 were conducting a search in the
kitchen area on the second floor of building #2.
The Captain (Victim #1) on Ladder 176 was
searching the rear bedroom while a fire fighter
on Ladder 176 went to the front of the
apartment to search. The second floor was filled
with heavy black smoke and heat, with no visible

fire (fire fighters were unaware the fire was
below them). The fire fighter searching the front
area of the second floor, experiencing extreme
heat and heavy black smoke, was in a crawling
position. He could hear yelling and screaming at
the rear of the hallway. Suddenly the heat
became intolerable, and he realized he must exit
immediately to survive. The fire fighter crawled
to the railing along the stairwell and dove over it
to escape the extreme heat, landing on fire
fighters in the stairwell. He was on fire when he
was removed from the building. At 2034 hours,
Battalion 44 ordered everyone out of the
building.
At 2035 hours there was a major change in
conditions, fire was now escalating in the front of
the building. It is believed that at 2035 hours,
when a major change in conditions occurred, the
rear area of the second floor (kitchen and
bedroom area) collapsed, trapping five fire
fighters (see Figure 4) (the Captain on Ladder
176 [Victim #1], the Lieutenant on 332 [Victim
#2] and two fire fighters on Engine 332, and the
Lieutenant on Ladder 103). The collapsed
section allowed the fire to vent freely up through
the floor and out the front and back of the
building, with flames leaping to the roof line.
At 2036 hours Battalion 44 received a Mayday
that was transmitted by the Ladder 103 Irons
Man for the collapse, but there was no
acknowledgment. A possible reason for this lack
of acknowledgment was the fire fighters had
fallen through the floor into the store below and

the handie-talkie became damaged creating a
stuck mike condition.
Also at 2036 hours, Battalion 44 transmitted to
dispatch a request for a third alarm for the fire
condition, unaware that a collapse had occurred.
At 2037 hours a fire fighter on Engine 332 exited
building #2 and reported to another fire fighter
that a collapse had occurred. At 2038 hours
Battalion 38, now on the scene, went to the
Page 5
second floor of building #2 and upon seeing the
collapsed area and a hand line extending down
into it, realized fire fighters had fallen to the first
floor. Battalion 44 requested that the dispatcher
have EMS respond for possible fire fighter
injuries.
At 2039 hours, Engine 231 advanced their
charged line into the area of collapse on the first
floor of building #2. At 2042 hours the Captain

(Victim #1) and one of the fire fighters on
Engine 332 were found in the collapsed area.
Shortly after, the other three fire fighters were
discovered trapped in the debris. It took
approximately 30 minutes to extricate the fire
fighters from the fallen and burning debris.
All injured fire fighters were immediately
transported to the hospital. The Lieutenant
(Victim #2) on Engine 332 was pronounced
dead on arrival. The Captain (Victim #1) on
Ladder 176 had 70% severe burns and died
approximately one month later. One fire fighter
was hospitalized for three days and has returned
to duty. Three fire fighters were hospitalized for
several weeks with severe burns, and have not
returned to active duty as of the date of this
report.
CAUSE OF DEATH
According to the medical examiner, the cause of
death for the Captain (Victim #1) was thermal
burns, resulting in cardiac arrest. The cause of
death for the Lieutenant (Victim # 2) was
crushing trauma and burns resulting in cardiac
arrest.
RECOMMENDATIONS/DISCUSSION
Recommendation #1: Fire departments should
ensure that Incident Command conducts an
initial size up of the incident before initiating
fire fighting efforts, and continually evaluates
the risk versus gain during operations at an
incident. [1-4, 8]
Discussion: One of the most important size-up

duties of the first-in officers is locating the fire
and determining its severity. This information
lays the foundation for the entire operation. First,
it determines the number of fire fighters and the
amount of apparatus and equipment needed to
control the blaze. Second, it assists in
determining the most effective point of fire
extinguishment attack, and the most effective
method of venting heat and smoke. Several
factors must be evaluated in conducting the size-
up, e.g., type of structure, time of day, contents
of the structure, potential hazards, etc. The size-
up should also include risk versus gain during
incident operations. The following general
factors are important considerations: (1)
occupancy type involved; (2) smoke conditions;
(3) type of construction; (4) age of structure; (5)
exposures; and (6) time considerations, such as
time of incident, time fire was burning before
arrival, time fire was burning after arrival, and
type of attack.
ensure that incident command always
maintains close accountability for all personnel
at the fire scene. [5-7]
Discussion: Accountability on the fireground is
paramount and may be accomplished by several
methods. It is the responsibility of every officer
to account for every fire fighter assigned to his or
her company and relay this information to
Incident Command. Fire fighters should not
work beyond the sight or sound of the
supervising officer unless equipped with a

Page 6
portable radio. This member should
communicate with the supervising officer by
portable radio to ensure accountability and
indicate completion of assignments and duties.
When the assigned duties are completed each
fire fighter should radio this information to the
supervisor then return to the supervisor for
additional duties. As a fire escalates and
additional fire companies respond, a
communication assistant with a command board
should assist the Incident Commander with
accounting for all fire fighter companies at the
fire, at the staging area, and at rehabilitation.
One of the most important areas for
accountability at a fire is an Incident Management
System.
ensure that some type of tone or alert that is
recognized by all fire fighters be transmitted
immediately when conditions become unsafe

for fire fighters. [7]
Discussion: There is a difference between
withdrawing fire fighters and calling for an
emergency evacuation of fire fighters. A normal
withdraw action is ordered when a fire is
spreading beyond the ability of fire fighters to
control it. An emergency evacuation is ordered
when an extremely serious emergency has
occurred or is about to happen, such as missing
fire fighter(s), explosion, or collapse. In an
emergency evacuation, unlike a withdraw, fire
department tools and hose are left behind and a
roll call or a head count must be conducted
immediately as there may be a missing fire fighter.
An emergency evacuation is a rare occurrence in
the fire service, and because of its rarity,
confusion and delay may occur when it is
ordered. For this reason, there should be a
prearranged audible signal, to alert fire fighters of
an emergency withdraw; fire departments should
train their members for an emergency evacuation
upon receipt of the signal. Fire fighters should
immediately exit the structure upon receipt of the
prearranged signal, leaving behind tools and
equipment, which can be removed later. Incident
commanders should use the prearranged
emergency evacuation signal whenever they
decide that conditions are unsafe
for interior fire fighting or an accident or
emergency involving a fire fighter(s).

Page 7
ensure that Rapid Intervention Crews/Teams
or Firefighter Assist and Search Teams (FAST
Truck) are in place in the early stages of an
incident [6]
Discussion: A Rapid Intervention Crew/Team or
Firefighter Assist and Search Team (FAST
Truck) should be positioned to respond to every
major fire. The team should report to the officer
in command and remain at the command post in
the event an intervention is required to rescue a
fire fighter(s). The Rapid Intervention
Crew/Team or FAST Truck should have all the
tools necessary to complete the job, e.g., a
search rope, rescue rope, first aid kit and a
resuscitator to use if a fire fighter becomes
injured. These teams can intervene quickly to
rescue fire fighters who become disoriented, lost
in smoke filled environments, trapped by fire,
involved in a structural collapse, or run out of
breathing air in their self-contained breathing
apparatus.

ensure that communication used on the
fireground, e.g., handie-talkies, will remain
operational in the event that one unit
malfunctions. [6]
Discussion: Effective communication on the
fireground between fire fighters, officers, and
command is imperative. When there is a
communication breakdown, command becomes
isolated from events occurring on the interior,
rear, sides, and roof of the structure. In this
incident, when a Mayday call was transmitted by
a fire fighter on the interior, it was never
acknowledged, possibly due to a handie-talkie
malfunction on the fireground.
Recommendation #6: Municipalities should
ensure that all modifications/renovations to
buildings are in compliance with current
building codes, i.e., any renovation or
remodeling does not decrease the structural
integrity of supporting members.
Discussion: Modifications, renovations, and
remodeling of buildings require building permits
to ensure all work done is in compliance with
current building codes and does not decrease the
structural integrity of supporting members. The
structure involved in this fire incident had been
remodeled and renovated several times in the
past. For example, supporting structures had
been moved or removed without appropriate
restructuring or support, thereby, creating a
hazard for the occupants and fire fighters in case
of a fire or other emergency. Specifically, a
relieving wall had been installed on the first floor

of building #2 (see Figure 5 ) that did not
adequately support the rear of the second floor
under fire conditions and the added weight of the
fire fighters.
REFERENCES
1. International Fire Service Training
Association. Essentials of fire fighting, 3rd ed.
Fire Protection Publications, March 1995.
2. Dunn V. Systems analysis, size-up: Part 1.
Firehouse, October 1996.
Page 8
3. Brunacini A [1985]. Fire command, Quincy,
MA: National Fire Protection Association.
4. Dunn V [1988]. Collapse of burning
buildings, a guide to fireground safety. Saddle
Brook, NJ: Fire Engineering Books and Videos.
5. Morris G, Gary P, Brunacini N, Whaley L
[1994]. Fireground accountability: The Phoenix

System, Fire Engineering, 147(4).
6. NFPA 1500: Standard on Fire Department
Occupational Safety and Health Program. 1997
ed. Quincy, MA: National Fire Protection
Association.
7. NFPA 1561: Standard on Fire Department
Incident Management System. 1995 ed. Quincy,
MA: National Fire Protection Association.
8. Kipp JD, Loflin ME [1996]. Emergency
incident risk management: A safety & health
perspective. New York: Van Nostrand Reinhold
Publishing.
INVESTIGATOR INFORMATION
Ted A. Pettit, Chief of the Trauma
Investigations Section, Surveillance and Field
Investigations Branch, Division of Safety
Research.
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